Although hypoglycemia typically is rare in patients without diabetes, it may present in patients with alcoholism, adrenal insufficiency, advanced cancer, critical illness, and insulin-secreting tumors, as demonstrated in a case presented at the American Association of Physician Assistants (AAPA 2022) conference held May 21 to May 25, 2022, in Indianapolis.

The case involved a 55-year-old woman with a history of hypothyroidism who presented with lightheadedness, nausea, 2 episodes of vomiting, and what she described as grogginess and drowsiness, explained study authors Jeffrey Vasiloff, MD, MPH, and Jeffrey Fisher, DMSc, MPAS, MSA, of Ohio University in Dublin, Ohio. The patient reported similar episodes over the past 8 months but those events were less severe and of shorter duration.

Medical History

Her medical history showed a 4-year history of seizures, hot flashes due to menopause, and hypercholesterolemia. She was currently taking levothyroxine, levetiracetam, atorvastatin, aspirin, and conjugated estrogens. She denied alcohol or drug use and is a smoker.


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Her vital signs are as follows: pulse, 104 beats per minute; temperature, 36.9 °C; respiratory rate, 14 breaths per minute; blood pressure, 90/59 mm Hg; and oxygen saturation, 97% on room air.

Physical Examination and Laboratory Findings

On physical examination, the patient was lethargic with no definite hyperpigmentation or goiter. Her abdomen was diffusely mildly tender without peritoneal signs, masses, or organomegaly. Her peripheral pulses were 1+/4 bilaterally; strength was 4+/5 in all major muscle groups. All other examinations are normal.

The patient’s initial laboratory results were within normal range except for a glucose level of 22 mg/dL and creatinine level of 1.4 mg/dL (previously was 0.9 in medical history), the study authors noted. The patient was initially administered 1.5 L saline and 25 g dextrose 50% (D50) followed by 150 mL/min dextrose 5% in water (D5W), the study authors explained. The next morning, her fasting blood glucose increased to 55 mg/dL.

An endocrine evaluation was ordered and showed a low cortisol level (2.5 μg/dL at 10 am), high adrenocorticotropic hormone (ACTH) level (168 pg/dL), and low C-peptide level (0.4 ng/mL); all other measures were normal.

Diagnosis

The patient was diagnosed with primary adrenal insufficiency based on the low cortisol level and high ACTH level, the study authors said. She was treated with hydrocortisone 100 mg IV every 6 hours on day 2. The patient’s hypotension and hypoglycemia resolved. Treatment was converted to oral prednisone and fludrocortisone.

The diagnosis was delayed for the following reasons, Dr Vasiloff said in an interview: “a) prior episodes were milder; b) in prior episodes, blood glucose was in the high 50s or low 60s; c) her history of epilepsy led clinicians to focus on that; d) she did not receive comprehensive evaluations; e) hypoglycemia is so rare in those not treated for diabetes.” 

 “It is important to think of adrenal insufficiency in patients with alterations of mental status due to hypoglycemia—especially in the presence of hypotension, nausea, vomiting, weakness, and fatigue,” Drs Vasiloff and Fisher concluded. “Our case eluded diagnosis for 8 months, but once the diagnosis was made and appropriate treatment was begun, the patient did well.”

Reference

Vasiloff J, Fisher J. An unusual case of hypoglycemia. Poster presented at: AAPA 2022; May 21-25, 2022; Indianapolis, IN.